Help MA-PD clients
Here are PDF resources that can help you manage your existing Blue Shield of California MA-PD clients in our plans for Medicare beneficiaries.
Including:
- Evidence of Coverage documents
- Star ratings
- Pharmacy directories
- Formularies
- Dental flyer and dental enrollment forms
- Authorization for the Use or Disclosure of Health Information
- Over-the-counter (OTC) items catalog
- Change of plan and disenrollment forms
Please note:
- All provider directories and materials you need for enrollment are located on the Arvato Storefront
The following browsers have been found to provide the best experience on the Blue Shield of California website: Google Chrome, Safari, Microsoft Edge, or Mozilla Firefox.
2024 Blue Shield Inspire (HMO) Evidence of Coverage
| 2024 Blue Shield Inspire (HMO) – Los Angeles and Orange counties | English (PDF, 1.1 MB) Spanish (PDF, 1.2 MB) |
| 2024 Blue Shield Inspire (HMO) – Alameda and San Mateo counties | English (PDF, 1 MB) Spanish (PDF, 1.2 MB) |
| 2024 Blue Shield Inspire (HMO) – San Joaquin, Stanislaus, Merced, and Santa Clara counties | English (PDF, 1.1 MB) Spanish (PDF, 1.2 MB) |
2024 Blue Shield Select (PPO) Evidence of Coverage
| 2024 Blue Shield Select (PPO) – Alameda County | English (PDF, 1.4 MB) Spanish (PDF, 1.2 MB) Chinese (Traditional) (PDF, 2 MB) |
| 2024 Blue Shield Select (PPO) – Orange and San Diego counties | English (PDF, 1.4 MB) Spanish (PDF, 1.2 MB) |
2024 Blue Shield 65 Plus (HMO) Evidence of Coverage
| 2024 Blue Shield 65 Plus (HMO) – Los Angeles and Orange counties | English (PDF, 1 MB) Spanish (PDF, 1.2 MB) |
| 2024 Blue Shield 65 Plus (HMO) – San Bernardino County | English (PDF, 1 MB) Spanish (PDF, 1.2 MB) |
| 2024 Blue Shield 65 Plus (HMO) – Riverside County | English (PDF, 1 MB) Spanish (PDF, 1.2 MB) |
| 2024 Blue Shield 65 Plus Plan 2 (HMO) – Los Angeles and Orange counties | English (PDF, 1.1 MB) Spanish (PDF, 1.2 MB) |
| 2024 Blue Shield 65 Plus Choice Plan (HMO) – Riverside and San Bernardino counties | English (PDF, 1.1 MB) Spanish (PDF, 1.2 MB) |
| 2024 Blue Shield 65 Plus (HMO) – San Diego County | English (PDF, 1.1 MB) Spanish (PDF, 1.2 MB) |
| 2024 Blue Shield 65 Plus (HMO) – Kern County | English (PDF, 1 MB) Spanish (PDF, 1.2 MB) |
| 2024 Blue Shield 65 Plus (HMO) – San Luis Obispo and Santa Barbara counties | English (PDF, 1.1 MB) Spanish (PDF, 1.2 MB) |
2024 Blue Shield Enhanced (HMO) Evidence of Coverage
2024 Blue Shield AdvantageOptimum Plan (HMO) Evidence of Coverage
2024 Blue Shield TotalDual Plan (HMO D-SNP) and Blue Shield Inspire (HMO D-SNP) Evidence of Coverage
| 2024 Blue Shield TotalDual Plan (HMO D-SNP) – Los Angeles and San Diego counties | English (PDF, 1.5 MB) Spanish (PDF, 2 MB) Arabic (PDF, 3 MB) Armenian (PDF, 2.1 MB) Chinese (Simplified) (PDF, 2.1 MB) Chinese (Traditional) (PDF, 2.1 MB) Farsi (PDF, 3.1 MB) Khmer (PDF, 3 MB) Korean (PDF, 6.4 MB) Russian (PDF, 2.6 MB) Tagalog (PDF, 2.1 MB) Vietnamese (PDF, 2.1 MB) |
| 2024 Blue Shield TotalDual Plan (HMO D-SNP) – Orange and San Bernardino counties | English (PDF, 1 MB) Spanish (PDF, 1.1 MB) |
| 2024 Blue Shield Inspire (HMO D-SNP) – Merced, San Joaquin, and Stanislaus counties | English (PDF, 987 KB) Spanish (PDF, 1.1 MB) |
2024 Star ratings
| Blue Shield 65 Plus (HMO), Blue Shield 65 Plus Plan 2 (HMO), Blue Shield 65 Plus Choice Plan (HMO), Blue Shield Inspire (HMO), and Blue Shield Enhanced (HMO) Medicare Star Ratings* | English (PDF, 170 KB) Spanish (PDF, 160 KB) |
| Blue Shield Inspire (HMO D-SNP) and Blue Shield TotalDual Plan (HMO D-SNP) Medicare Star Ratings* | English (PDF, 196 KB) Spanish (PDF, 138 KB) Armenian (PDF, 154 KB) Arabic (PDF, 161 KB) Chinese (Simplified) (PDF, 130 KB) Chinese (Traditional) (PDF, 135 KB) Farsi (PDF, 182 KB) Khmer (PDF, 118 KB) Korean (PDF, 118 KB) Russian (PDF, 167 KB) Tagalog (PDF, 94 KB) Vietnamese (PDF, 187 KB) |
| Blue Shield AdvantageOptimum Plan (HMO) and Blue Shield AdvantageOptimum Plan 1 (HMO) Medicare Star Ratings* | English (PDF, 163 KB) Spanish (PDF, 135 KB) |
| Blue Shield Select (PPO) Medicare Star Ratings* | English (PDF, 163 KB) Spanish (PDF, 135 KB) Chinese (PDF, 132 KB) |
*Every year, Medicare evaluates plans based on a 5-star rating system.
2024 Pharmacy directory
| Blue Shield 65 Plus (HMO), Blue Shield 65 Plus Plan 2 (HMO), Blue Shield 65 Plus Choice Plan (HMO), Blue Shield AdvantageOptimum Plan (HMO), Blue Shield AdvantageOptimum Plan 1 (HMO), Blue Shield Inspire (HMO), Blue Shield Select (PPO), and Blue Shield Enhanced (HMO) | English (PDF, 2.9 MB) Spanish (PDF, 2.9 MB) |
| Blue Shield Inspire (HMO D-SNP) San Joaquin/Stanislaus/Merced counties and Blue Shield TotalDual Plan (HMO D-SNP) Orange/San Bernardino counties | English (PDF, 3.1 MB) Spanish (PDF, 3.1 MB) |
| Blue Shield TotalDual Plan (HMO D-SNP) Los Angeles/San Diego | English (PDF, 4.5 MB) Spanish (PDF, X MB) Chinese (Simplified) (PDF, X MB) Chinese (Traditional) (PDF, X MB) Arabic (PDF, 4.2 MB) Armenian (PDF, 4.2 MB) Cambodian (PDF, X MB) Farsi (PDF, 4.4 MB) Korean (PDF, X MB) Russian (PDF, X MB) Tagalog (PDF, X MB) Vietnamese (PDF, X MB) |
2024 MA-PD formularies
2024 Optional supplemental dental HMO and PPO plan flyer and enrollment form
Authorization for the Use or Disclosure of Health Information
2024 Over-The-Counter (OTC) items catalog
2024 MA-PD Plans with the OTC Items Benefit: Blue Shield Inspire (HMO) – Los Angeles, Orange, Alameda, San Mateo, Santa Clara, San Joaquin, Stanislaus, and Merced counties |
OTC Catalog English (PDF, 2.4 MB) |
2024 Change of plan and disenrollment forms
| MA-PD Disenrollment forms | English (PDF, 62 KB) Spanish (PDF, 65 KB) Arabic (PDF, 147 KB) Armenian (PDF, 120 KB) Cambodian (PDF, 156 KB) Chinese (Simplified) (PDF, 118 KB) Chinese (Traditional) (PDF, 129 KB) Farsi (PDF, 160 KB) Korean (PDF, 85 KB) Russian (PDF, 137 KB) Tagalog (PDF, 61 KB) Vietnamese (PDF, 103 KB) |
| MA-PD (HMO) Change of Plan forms | English (PDF, 240 KB) Spanish (PDF, 269 KB) Chinese (Traditional) (PDF, 548 KB) Korean (PDF, 338 KB) Vietnamese (PDF, 327 KB) |
| MA-PD (PPO) Change of Plan forms | English (PDF, 222 KB) Spanish (PDF, 241 KB) Chinese (Traditional) (PDF, 571 KB) |
| MA-PD (TotalDual HMO D-SNP) Change of Plan forms | English (PDF, 218 KB) Spanish (PDF, 200 KB) Arabic (PDF, 286 KB) Armenian (PDF, 259 KB) Cambodian (PDF, 242 KB) Chinese (Simplified) (PDF, 299 KB) Chinese (Traditional) (PDF, 306 KB) Farsi (PDF, 282 KB) Korean (PDF, 218 KB) Russian (PDF, 236 KB) Tagalog (PDF, 183 KB) Vietnamese (PDF, 266 KB) |
| Optional Supplemental dental disenrollment forms | English (PDF, 51 KB) Spanish (PDF, 43 KB) |
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Page last updated: 1/1/2024
